Pediatric Mental Health Through the Pandemic: A Path Forward

Michelle Dalal, MD

ThrOugh thIs panDemIC, there Were sO many DIsruptions to the normal routines of daily life that it became difficult to know what to expect, leading to worries and anxiety for kids and their families. Feelings of hopelessness and sadness grew, especially amongst teens, while thoughts of suicide and actual suicide attempts rose slightly from pre-pandemic times. The mental health crisis had been present before the pandemic, but through the pandemic, certain populations have experienced significantly increased mental health needs such as LGBTQ youth, youth in poverty, racial and ethnic minority youth, and youth whose families had been affected by COVID.

The combination of worries, sadness, and trauma led to increased mental health concerns that inundated emergency departments, primary care offices, and mental health clinics, and overwhelmed the existing medical system. A mental health emergency was declared with the hopes of funneling more resources to the mental health crisis — but as with any crisis, stresses grew as people began to find it difficult to access therapists and psychiatrists to meet the mental health needs of their kids.

Now, as we are two years into the pandemic, the focus needs to be redirected on the path forward. As outlined in the Surgeon General Report, Protecting Youth Mental Health (1), there are many factors which shape youth mental health including individual, family, community, environmental, and societal factors. We have an opportunity to influence each of these factors to help alleviate the mental health crisis and it starts by what we can do day to day.

First and foremost, we must listen nonjudgmentally to kids and spend time with them to understand their concerns. Studies show the presence of one stable, caring supportive relationship can change the trajectory of a child’s life (2). We can also offer training to individuals to enable them to help someone who is experiencing worsening sadness or anxiety or who is in crisis. Training for non-medical personnel can be considered through programs such as the Youth Mental Health First Aid by the National Council for Mental Wellbeing.

In the clinical setting, mental health concerns can be addressed quickly and expediently by all who provide care, from front staff and nurses to providers and behavioral health clinicians. We can ensure behavioral health screenings — such as the PSC-17, Y-PSC-17, PHQ-9, or GAD-7 — are being completed at each well child visit and, when a screen is elevated, that a comprehensive interview is completed. The United

States Preventative Services Task Force recommends screening for depression for all kids ages 12 to 18 (3) and will soon be recommending anxiety screening for kids ages 8 to 18.

Following screenings and subsequent interviews, urgent or non-urgent collaborative action plans can be developed with the families. Massachusetts has the benefit of crisis intervention teams that can be accessed if needed. If suicidal ideation is present and safety plans cannot be created, then children and teens should be sent to emergency departments for emergent evaluations. If acute needs are not present, families should be informed about the diagnosis and treatment plans. These treatment plans could include a wide range of interventions, from lifestyle interventions — like improved sleep, healthy eating, increased physical activity, stress management, avoiding risky substances like marijuana, nicotine, and alcohol, and increasing social connections — to psychotherapy and medications. The plans should also include routine follow up by behavioral therapists or primary care providers to ensure continuity of care and follow-up for progression or worsening of symptoms. Behavioral therapists can be accessed within clinics, in the community or online.

Kids and their families need the reassurance that they have a team working with them to help them through any mental health challenges. This can include teachers, counselors, family members, primary care providers, and others who are stakeholders in their well-being. Working collaboratively and individualizing treatment plans can be very effective in mental health care.

It takes knowledge, skill, and time to deal with mental health issues: Time is needed to talk to patients, understand concerns, make diagnoses, coordinate care, and ensure appropriate follow-up. As clinicians, we need support to ensure we can provide the best mental health care by encouraging behavioral health integration at every level and access to urgent services through programs such as the Massachusetts Children Psychiatry Access Program (MCPAP) when practices do not have resources to fully integrate behavioral health providers. Health systems need to change to allow adequate time to see patients and reimbursement for mental health visits.

Lastly, we need to advocate for our patients outside the clinical setting so that we influence the environmental and societal factors which affect youth mental health. The mental health of kids is intricately linked to everything that occurs around them. We must continue to advocate for policies such as longer recess times, longer lunch times, later school start times, access to in school counselors, and so much more.

Because mental health is a part of overall health and wellness, policies which ensure good physical health are the exact same ones that will continue to boost mental health for kids and families alike. Every small step we can take to address, approach, and advocate for improved mental health for our youth can lead to improved quality of life and reduced mental health issues as an adult. All of us can do our part to improve mental health for youth each and every day. +

Michelle Dalal, MD, Medical Director of University Health Services, Northeastern University

HELPFUL RESOURCES:

National Suicide Prevention Line: 1-800-273 8255

Mass Health Crisis Intervention Services

(Patients with any Insurance can Access): 1-877-382-1609

HELPFUL WEBSITES:

Massachusetts Child Psychiatry Access Program- MCPAP: https://www.mcpap.com/

Youth Mental Health First Aid: https://www.mentalhealthfirstaid.org/population-focused-modules/youth/

REFERENCES

1. Office of the Surgeon General (OSG). Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory Washington (DC): US Department of Health and Human Services; 2021.

2. National Scientific Council on the Developing Child. (2015). Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience: Working Paper 13. http://www.developingchild.harvard.edu

3. Albert L. Siu, , on behalf of the U.S. Preventive Services Task Force , et al; on behalf of the U.S. Preventive Services Task Force .. Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med.2016;164:360-366.